VIII.
CPR IN AUSTERE SETTINGS
Most medical books start off with a chapter on cardio-pulmonary resuscitation, so you might wonder why this subject has not been given coverage so far in this volume. The answer is based on hard realities that we must confront in a survival scenario.
Although CPR is an important skill that everyone should know, there are fewer situations in a collapse scenario where it will return a victim to normal function. There are only a small number of circumstances where a patient goes from being a patient in need of resuscitation to a person who is back to normal.
CPR is best used as a stabilization strategy. You want to get the heart pumping and breathing supported so that you can get your patient as quickly as possible to a facility where there are ventilators, defibrillators, and other high technology. But what about a situation where this technology is no longer available?
There won’t be cardiac bypasses for your patient who has had a heart attack. There won’t be surgical suites for your patient with a shotgun blast to the abdomen or chest. The sobering truth is that many of these injuries will be mortal wounds. This means that death is the inevitable end result, no matter what you try to do. The poor prognosis for these people in hard times is tragic; it makes you truly appreciate the benefits of modern medicine.
There are still instances, however, where CPR may actually restore a gravely ill person to normal function. Airway obstruction by a foreign object can be dealt with by using the Heimlich maneuver. Environmental conditions, such as hypothermia, heat stroke, or smoke inhalation, will often respond to resuscitative efforts with complete recovery. Severe anaphylactic reactions may require CPR until the patient responds to epinephrine (EpiPen) and resolves the attack. Rarer events, such as lightning strikes or drowning, may require resuscitation to revive the victim.
I chose not to put a large number of illustrations or an entire course on how to do CPR in this book. There is no substitution for learning it in person by taking a hands-on course, mandatory for anyone who expects to be a caregiver in a long-term survival scenario.
Airway Obstruction
One situation where you can save a life by knowing how to perform a simple maneuver is in the case of an airway obstruction. This most commonly occurs as a result of food lodging in the back of the throat and cutting off respiration.
If you see a conscious adult in sudden respiratory distress, ask quickly, “Are you choking on something?” If they can answer you, there is still air passing into their lungs. If it’s a complete blockage, they will be unable to speak. They will probably be agitated and holding their throat, but they will hear you and (frantically) nod their head “yes.” Quick action will be necessary.
Tell the victim that you’re there to help them and immediately get into position for the Heimlich maneuver, otherwise known as an “abdominal thrust.” Get behind the victim and make a fist with your right hand. Place your fist above the belly button; then, wrap your left arm around the patient and grasp the right fist. Make sure your arms are positioned just below the ribcage. With a forceful upward motion, press your fist abruptly into the abdomen. You might have to do this multiple times before you dislodge the foreign body.
If your patient loses consciousness and you are unable to dislodge the obstructive item, place the patient in a supine position and straddle them across the thighs or hips. Open their mouth and make sure that the object can’t be removed manually. Give several upward abdominal thrusts with the heels of your palms above the belly button (one hand on top of the other). Check again; you might have partially dislodged the offending morsel of food.
In old movies, you might see someone slap the victim hard on the back; this is unlikely to dislodge a foreign object and will waste precious time. An exception to this is in an infant: Place the baby over your forearm (facing down) and apply several blows with the heel of your hand to the upper back.
An extreme method that can be used to open an airway is the tracheotomy. This procedure, also called a cricothyroidotomy, involves cutting an opening in the windpipe below the level of an obstruction. Tracheotomy should be performed only when an airway obstruction completely prevents the ability to breathe after multiple Heimlich maneuvers have been unsuccessful.
To perform a tracheotomy, you will need a sharp blade and some sort of tube, even a straw. Don’t worry about antiseptics for now; you are performing this procedure because someone may die in the next few minutes.
The procedure goes as follows:
1. Start at the Adam’s apple. Move about 1 inch down the neck until you feel a bulge. This is the cricoid cartilage.
2. Make a horizontal incision with a knife or a razor blade in the crease between the Adam’s apple and the cricoid cartilage. This incision can be less than 1 inch long.
3. Incise downward ½-inch deep or so. There shouldn’t be a lot of blood.
4. Below the incision, you’ll see the greyish crico-thyroid membrane. Make an incision through it; this should enable passage of air into the lungs. Be careful not to cut too deeply.
5. Place something hollow in the opening 1 inch deep, to maintain a clear airway. A straw would do in a pinch. Try to get it a couple of inches down the windpipe; doing this makes it less likely to fall out.
6. If the patient fails to breathe on their own, you may need to perform CPR, including rescue breaths through the tube you inserted.
This obviously is a dangerous procedure. A lot can go wrong, but the patient is dying and it may be your last resort. Only consider it when help is not on the way, and you have tried every other option first.
CPR in the Unconscious Patient
If you come across someone who is apparently unconscious, be certain to first verify their mental status. Simply ask them loudly, “Are you OK?” No answer? Grasp the person’s shoulders and move them gently while continuing to ask them questions. If they are still unresponsive, it’s time to check their pulse and respiration. If they aren’t breathing or no pulse is felt, it’s time to start resuscitative efforts:
1. Place your patient in a position so that they are lying flat on their back.
2. Begin chest compressions by placing the heel of your hand in the middle of the chest palm down, over the lower half of the breastbone at the nipple level.
3. Place your other hand on top and interlace your fingers.
4. Position yourself directly above your hands (arms straight) and press downward in such a fashion that the breastbone (sternum) is compressed about 2 inches. You would want less pressure in a child.
5. Allow the chest to recoil completely. Perform 30 compressions at a rate of at least 100 per minute. Be certain to avoid the rib cage, as broken ribs are a common complication of the procedure.
After 30 chest compressions, evaluate the victim for breathing and clear the airway. Look quickly inside the mouth for a foreign object. If there is none, place the patient’s head in a position that will enable the clearest passage for air to enter the body. This is called the “chin lift.” Tilt the head back (unless there is evidence of a neck injury); grasp the underside of the chin and lower jaw with one hand and lift. Using this method, the tongue and other throat structures are placed in a position that helps the patient take in oxygen. A useful medical device in this situation is an airway. There are both rigid oral and flexible nasal versions that help keep the patient’s airway open.
If you aren’t trained in CPR, just continue compressions. If you do know CPR, you may give 2 long breaths mouth-to-mouth (3–5 seconds between each one). These are called “rescue breaths.” Pinch the nose closed to prevent the escape of air that needs to get into the lungs.
You can determine the effectiveness of your efforts by watching the patient’s chest rise as you give the breaths. Continue giving 30 compressions, then 2 rescue breaths for 5 cycles or 2 minutes. Then, check your patient’s status. Once you have started CPR, don’t stop until the patient has responded or it is clear that they will not.
Many people are reluctant to perform rescue breaths because of concerns about contagious disease. If this is an issue, take a nitrile glove and cut the ends off the two middle fingers. Place over the victim’s mouth (cut glove fingers down) as you breathe for them. This provides a barrier that still enables air flow. Commercially produced protective CPR masks are also available.
Another useful item for your medical supplies is a bag valve mask, otherwise known by the brand name AmbuTM bag. This can be placed on the patient’s mouth to form a seal through which you can ventilate them by pressing on an air-filled “bag.” This will force air into the respiratory passages.
After 30 minutes of CPR without result, the pupils of the patient’s eyes will likely be dilated and not respond to light. At this point, your patient has expired and you can cease your efforts. Some may feel this is not long; in truth, however, just a few minutes without oxygen are enough to cause irreversible brain damage. In a grid-down situation, you will not be equipped to provide long-term chronic care to someone who no longer has brain activity.
There are units known as defibrillators available that, though quite expensive, may be useful in a cardiac arrest. These machines produce an electric shock to the heart and sometimes can restart a pulse that has stopped. If caused by a heart attack, a patient suffering a cardiac arrest without defibrillation will have a very low survival rate.
“Home” defibrillators can be found online and are surprisingly easy to use:
1. Turn the unit on and connect the electrodes per the instructions.
2. Place one electrode pad on the right chest above the nipple and below the collarbone.
3. Place the other on the left chest outside the nipple and several inches below the armpit. The unit will analyze the heart rate (or lack of one) and tell you whether a shock is necessary.
4. If a shock is indicated, clear everyone away from the patient and press the button to activate the electric shock.
5. Recheck vital signs and begin chest compressions as needed.
If you are successful in establishing a pulse and breathing in your unconscious patient and, for some reason, you must leave them, position them so that they will not vomit and possibly aspirate stomach acid into the lungs (see image below). This is known as the “recovery position.”
The recovery position
To achieve the recovery position, take the following steps:
1. Kneel on one side facing the patient.
2. Position the patient’s arm (the one closest to you) perpendicular to the body.
3. Flex the elbow.
4. Position the other arm across the body.
5. Bend the leg that is farthest from you up; reach behind the knee and pull the thigh toward you.
6. Use your other arm to pull the shoulder farthest from you while rolling the body toward you.
7. Maintain the upper leg in a flexed position so that the body is stabilized.
As we stated above, although CPR will be of limited use when modern medical facilities are not available, it is still important to know. A survival medic should not only be skilled in performing CPR, but should also teach it to every group member.
HEADACHE
Headaches are one of the most common medical symptoms that you will see in your role as medic. Although there are almost more causes for headaches than you can reasonably write down, in a survival setting, it’s good to know the common causes are:
Hunger
Dehydration
Stress
Infections
Fevers
Elevated blood pressure
Caffeine or alcohol withdrawal
Fumes
Headaches that occur suddenly may be related to infection, especially in the ears or sinuses, colds, or flus, but may also herald a life-threatening event, such as a stroke.
Headache Types
Tension headache
By far, the most frequently seen type of headache is the tension headache. This is caused by spasms of the muscles of the neck and head. Tension headache is usually seen bilaterally (on both sides) and in the back of the head, neck, or both. They may be related to stress, anxiety or depression, a head injury, or even just time spent with the head or neck in an abnormal position. A sensation of pressure or tightening is the most common symptom.
This type of headache may be improved by massaging the back of the neck and temples. Ibuprofen and acetaminophen are old standbys as treatment. Identifying the situation that triggers the headache may help avoid future episodes.
Sinus headache
Sinus headaches are often caused by infections. They are associated with constant pain in the front of the face. A sinus is an air-filled cavity in the bones of the skull. The forehead, cheeks, or the bridge of the nose are the areas affected most by sinus infections; they often may be one-sided, which will help you to make the diagnosis. Sudden head movement may intensify the pain.
To treat headaches caused by sinusitis, amoxicillin (veterinary equivalent: Fish Mox Forte), 500 mg—times a day for a week, is a reasonable first choice. If you are allergic to the penicillin family of drugs, consider sulfamethoxazole/trimethoprim (veterinary equivalent: Bird Sulfa), either 160 mg or 800 mg (as needed) twice daily. Nasal decongestants, such as pseudoephedrine (Sudafed), may give some relief; so may sterile saline nasal rinses.
Migraines
Migraine headaches are common. The exact cause of migraines is uncertain but may be related to spasms in the blood vessels. Women are more susceptible than men.
A specific pattern of symptoms is seen in this variety of headache:
Pain behind the eye (usually one-sided)
Sensitivity to light, noise or odors
Nausea and vomiting (causing loss of appetite or stomach discomfort)
Vision changes (blurring, light and color phenomena)
Bed rest in the dark will be helpful here, as well as ibuprofen or acetaminophen. Some migraine medications use caffeine, which can be effective. Teas and coffee might be alternatives in an austere setting. If you are a chronic migraine sufferer, ask your physician for sumatriptan (ImitrexTM), a strong anti-migraine medication, to stockpile.
Less common causes of headache include a serious infection of the central nervous system (meningitis). Along with headaches, meningitis presents with a stiff neck, fever, and possibly a rash. This condition may be caused by bacteria, viruses, or even fungi. You could treat this condition with antibiotics and antivirals but expect variable results.
Uncontrolled high blood pressure or a burst blood vessel in the brain may cause a stroke. Besides the sudden onset of a severe headache, the patient may lose strength in the arm and leg on one side, have decreased motion on one side of the face, and absent or slurred speech.
Natural Headache Relief
If you would like a strategy to deal with a headache without drugs, try the following:
• Place an ice pack where the headache is.
• Have someone massage the back of your neck.
• Using two fingers, apply rotating pressure where the headache is.
• Lie down in a dark, quiet room. Get some sleep if at all possible. If your blood pressure is elevated, lay on your left side (pressure is usually lowest in this position).
• Track what you were doing or perhaps what you ate before the headache started; avoid that activity or food if possible.
A number of herbal remedies are available that might help headache. Feverfew is an herb that may decrease blood vessel constriction and is anti-inflammatory. This can be taken on a daily basis (1–2 leaves) for those with chronic problems. (Warning: don’t use feverfew during pregnancy or nursing.) Gingko biloba has a similar action. For external use, consider lavender or rosemary oil. Massage each temple with 1–2 drops every few hours.
The pain of tension headaches can be relieved if you use herbs that have sedative and antispasmodic properties. Teas made from valerian, skullcap, lemon balm, and passionflower have both. Herbal muscle relaxants may also help; rosemary, chamomile, and mint teas are popular options.
EYE ISSUES
By picking up this book, you have demonstrated that you have excellent foresight. Unfortunately, that doesn’t mean that you necessarily have excellent eyesight. Human beings aren’t perfect, and one of our most common imperfections is that of being nearsighted (having myopia) or farsighted (having hyperopia).
Most of us correct our eye issues with eyeglasses or contact lenses. In a survival setting, these vision aids become more precious than gold, but most people haven’t made provision for replacement pairs in their storage. I can’t think of anything scarier than being on your own and not being able to see. Therefore, your medical supplies should have multiple pairs. You might even consider corrective eye surgery (laser-assisted in situ keratomileusis, or LASIK). It is highly successful and one of the safest surgical procedures in existence.
Eye-protection glasses are another required item. Many of us with perfect vision will be negligent about wearing eye protection when we chop wood or other chores likely to be part of off-grid living. Without eye protection, the risk of injury when performing some strenuous tasks will be much higher.
Most people don’t consider sunglasses to be a medical supply item, but they are. Even if you are just taking a hike outdoors, sunglasses provide eye protection from ultraviolet light. UV light causes, over time, damage to the retinal cells, which can lead to a clouding over of your eye’s lenses (cataracts). This condition can only be repaired by surgery that will not be available in a collapse. Protection from UV light helps prevent long-term damage.
Sunglasses may also prevent a type of vision loss known as “snow blindness” (photokeratitis), a burning of the cornea that comes from overexposure to UV light. This is painful and dangerous in the wilderness, but, luckily, will go away on its own if the affected eye is covered with a patch. Bottom line: Whenever you are outdoors, you should ask yourself why you aren’t wearing eye protection.
Infections of the Eye
There are various eye conditions that will be more common in a grid-down situation. The most common will be conjunctivitis (pinkeye). Conjunctivitis is an inflammation that causes the affected eye to become red and itchy, and many times will cause a milky discharge. It can be caused by chemical irritation, a foreign body, an allergy, or an infection.
Pinkeye is highly contagious among children because of their habit of rubbing their eyes and then touching other people or items. While children may do it more than adults, studies have shown that people of all ages commonly touch their faces and eyes with their (often dirty) hands throughout the day.
Irritated red eyes with tears may also be seen in allergic reactions, which can be treated with antihistamines orally or antihistamine eye drops. Eye allergies can be differentiated from eye infections in that eye allergies are less likely to have a milky discharge associated with them.
To avoid spreading the germs that can cause eye infections, do the following:
• Don’t share eye drops with others.
• Don’t touch the tip of a bottle of eye drops with your hands or your eyes, because that can contaminate it with germs. Keep the bottle 3 inches above your eye.
• Don’t share eye makeup with others.
• Never put contact lenses in your mouth to wet them. Many bacteria and viruses—maybe even the virus that causes cold sores (herpes)—are present in your mouth and could easily spread to your eyes.
• Change your contacts often. The longer they stay in your eyes, the higher the chance is that your eye can get infected.
• Wash your hands regularly.
Antibiotics such as doxycycline, 100 mg twice a day for a week, will relieve infectious conjunctivitis. To treat pinkeye using natural products, pick one or more of the following methods:
• Apply a wet chamomile or goldenseal tea bag to the closed, affected eye for 10 minutes every 2 hours.
• Make a strong chamomile (Euphrasia officinalis; also known as eyebright) tea. Let it cool and use the liquid as an eyewash (using an eyecup) 3–4 times daily.
• Use 1 teaspoon of baking soda in 2 cups of cool water as an eyewash solution.
• Dissolve 1 tablespoon of honey in 1 cup hot water; let cool and use as eyewash.
• Use any of the solutions described above on gauze or cloth, and then apply a compress to the affected eye for 10 minutes every 2 hours. Placing a slice of cucumber over the eyes can cool them, providing relief.
Another common eye issue is a sty, essentially a pimple which has formed on the eyelid. It causes redness and some swelling and is generally uncomfortable. Warm, moist compresses are helpful in enabling the sty to drain. Any of the previously mentioned antibiotic or natural treatments for conjunctivitis can also be used.
Eye Trauma
The great majority of eye injuries are avoidable with a little planning. Despite this, it is likely you will come upon an eye injury at one point or another. Here are just a few of the ways eye injuries occur:
• Accidents while using tools
• Spatter from bleach or other household chemicals
• Hedge clippers or lawn mowers
• Grease splatter from cooking
• Chopping wood
Whenever anyone presents to you with eye pain, do a careful examination. A foreign object is the most likely cause of the problem. Use a moist cotton swab (Q-tip) to lift and evert the eyelid. This will enable you to effectively examine the area. An amount of clean water can be used as irrigation to flush out the foreign object. Alternatively, touch the object lightly with the Q-tip to dislodge it.
After ensuring that there is no foreign object still present, look at the cornea, the clear layer of tissue over the iris (the colored part of the eye). The cornea protects the eye and helps with focusing. Damage to this layer of tissue, called a “corneal abrasion,” may be caused by any of the things listed earlier; people who wear contact lenses are especially at risk. The patient will probably relate to you that they feel as if there’s a grain of sand in their eye.
After cleaning the eye out with water and using antibiotic eye drops (if available), cover the closed eye with an eye pad and tape. Ibuprofen is useful for pain relief. Over the next few days, the eye should heal.
Occasionally, blunt trauma to the eye or even simple actions such as coughing or sneezing may cause a patch of blood to appear in the white of the eye. This is a subconjunctival hemorrhage (or hyphema) and certainly can be alarming to the patient. Luckily, this type of hemorrhage is not dangerous, and will go away on its own without any treatment. If there is a loss of vision associated with the hyphema, however, there is cause for concern. Evaluate this injury as described for abrasions. Keeping the patient’s head elevated will enable any blood to drain to the lower part of the eye chamber. This strategy may help preserve vision.
NOSEBLEEDS
It’s a rare individual who has never had a nosebleed. The nose has many tiny blood vessels and is situated in a vulnerable position because it protrudes from the face.
Nosebleeds can occur from outside causes, such as trauma to the face, or by factors that affect the inside of the nose, such as excessive “picking” or irritation from upper respiratory infections. Environmental factors, such as cold or dry climates, may also play a role. In rare cases, underlying illness, such as faulty blood clotting, may be implicated.
Do the following to effectively stop a nosebleed in a patient:
1. Have the patient sit upright with their head tipped slightly forward. Although you may have been taught to tilt your patient’s head backward, this may just cause blood to run down the back of the throat.
2. Have the patient breathe through their mouth.
3. Using your thumb and index finger, firmly pinch the soft part of the nose just below the bone. Push towards the face. Spray the nose with a medicated nasal spray, such as oxymetazoline hydrochloride, 0.05 percent (Afrin), before applying pressure.
4. Apply an ice pack to the side that is bleeding. Cold constricts the blood vessels and may help stop the bleeding.
5. Apply pressure for 5–10 minutes. Be patient.
6. Check to see if your patient’s nose is still bleeding after 10 minutes. If still bleeding, hold it for 10 more minutes.
7. Place a little petroleum jelly inside the nose.
In prolonged cases, a strip cut from gauze impregnated with Celox or QuikClot may be placed delicately in the nose with blunt tweezers or a Kelly clamp. Alternatively, the bleeding nostril can be flushed with sterile saline; then, gently introduce a thin strip of cloth drenched in epinephrine (from an EpiPen or other anaphylactic shock kit) gently into the nostril. Do not remove the packing for several hours. Other commercial products, such as NasalCEASETM or WoundSeal, are available and are thought to be effective; you should consider them as medical storage items.
Whether the bleeding is due to trauma or not, blowing the nose to eject blood and clots should be avoided, as it may restart the bleeding.
The “Broken” Nose
What is usually referred to as a “broken” nose consists of either an actual fracture of the delicate bones that connect the nose to the rest of the skull, or just damage to the cartilage in the nose. If the nose bones are fractured, the patient will find that any pressure on the nose is very painful. Although it may be painful, an obvious deformity of the nose due to trauma can possibly be adjusted back into place.
Damage to the cartilage may also cause deformity and difficult breathing due to swelling. You may choose to reduce the deformity by using both hands to straighten the cartilage. This may be appropriate as the injured nose, if deformed, will not straighten out by itself. Be aware that this may cause further damage.
You might then consider taping the nose in its normal position. Place some ice wrapped in a cloth over the nose for periods of 20 minutes, taking breaks in between to avoid damage from the cold, throughout the next 48 hours to reduce swelling and discomfort. Acetaminophen and ibuprofen will also be helpful in this circumstance. Swelling in nasal passages may be improved with a nasal decongestant.
EARACHE
It’s a rare parent who hasn’t had to deal with this problem in their child at one point or another. In some cases, it’s a chronic problem that affects the quality of life of an otherwise healthy child. The most common symptom relating to the ear is pain, usually due to an infection.
The ear is divided into three chambers: the outer ear, middle ear, and inner ear. The most common ear infections will be in the external and middle ear chambers.
The easiest way to prevent ear infections is to carefully use cotton swabs moistened with rubbing alcohol to dry the ear canal after swimming or excessive sweating. Forceful use of a cotton swab, however, is to be avoided; normally, you shouldn’t place anything in the ear canal smaller than your elbow.
Ear Infections
Otitis Externa
Inflammation of the ear is called “otitis.” Otitis externa, also known as “swimmer’s ear,” is an infection of the outer ear canal, and most commonly affects children aged 4–14 years old. Cases peak during summer months, when most people go swimming. Bacteria will accumulate and multiply in water or sweat. Once caught in the ear canal, inflammation and discomfort ensue.
Symptoms of otitis externa include the following:
Gradual development of an earache or, possibly, itching
Pain worsened by pulling on the ear
Ringing in the ears (tinnitus) or decreased hearing
A “full” sensation in the ear canal, with swelling and redness
Thick drainage from the ear canal
Standard treatment may include a warm compress to the ear to help with pain control. An antibiotic or steroidal ear drop will be useful, and should be applied for 7 days. To get the most effect from the medicine, place the drops in the ear with the patient lying on their side (the opposite one from the affected ear). They should stay in that position for 5 minutes to completely coat the ear canal. Severe cases may be treated with oral antibiotics (such as amoxicillin) and ibuprofen.
Otitis Media
The most common cause of earache is an infection of the middle ear, otitis media. When visualized with an otoscope (a scope for examining the ear canal), the eardrum is normally shiny and grayish. When there is an infection in the middle ear canal, the eardrum will appear dull. This is because there is pus or inflammatory fluid behind it. Standard treatment often includes oral antibiotics and ibuprofen, especially in adults with the infection.
Otitis media is most common, however, in infants and toddlers. This is why mothers are always cautioned against bottle or breast-feeding with their baby lying flat. You can expect one or more of the following with otitis media:
Pain, more so when lying down
Difficulty sleeping, and irritability
Fever
Loss of appetite
Loss of balance
Holding or pulling the affected ear
Drainage of fluid from the affected ear
Difficulty hearing from the affected ear
A number of natural remedies are available for earache. Try the following procedure:
1. Mix rubbing alcohol and vinegar in equal quantities, or alternatively, hydrogen peroxide.
2. Place 3–4 drops into affected ear.
3. Wait 5 minutes; then, tilt head to drain out the mixture.
4. Use plain warm olive oil and place 2–3 drops into the ear canal. A cotton ball with 2 drops of eucalyptus oil may be secured to the ear opening during sleep.
Other Ear Problems
Inner-ear canal issues, including inflammation (otitis interna), often cause dizziness (vertigo). These patients commonly feel nauseous as well as dizzy. Treatment with dimenhydrinate (DramamineTM) can help with symptoms. Amoxicillin (veterinary equivalent: Fish Mox Forte), 500 mg 3 times a day for 7 days, is an appropriate antibiotic therapy if the otitis was caused by an infection.
Ear wax (cerumen) is a chronic problem for certain people. Cerumen is normal and protective in healthy ears. It traps dust particles before they can reach the ear drum.
Normally, people use cotton swabs to remove ear wax, but this method often pushes ear wax farther in. Cleaning the opening of the ear canal with a twisted, moist washcloth is safer.
When, for whatever reason, cerumen is lodged against the eardrum, it can affect hearing. Other symptoms include the following:
Earache
Hearing loss
Itching
Odor or discharge
Ringing in the ear (tinnitus)
Commercial ear rinses with special syringes are available for treatment. Standard home remedies involve a few drops of mineral or baby oil in the ear. This softens the wax, which can then be flushed out with 3 percent hydrogen peroxide. Some people just use the hydrogen peroxide by itself.
HEMORRHOIDS
Hemorrhoids are painful, swollen veins in the lower portion of the rectum that often protrude from the anus. A likely cause is low dietary fiber, which leads to hard stools. This causes straining during bowel movements. Hemorrhoids are extremely common during pregnancy.
Hemorrhoids are asymptomatic unless they develop a clot and become inflamed (thrombosis), which will cause constant pain and may even make it difficult to sit down.
Hemorrhoids may be internal or external. Symptoms include the following:
Anal itching
Bleeding, usually seen on toilet tissue
Pain, which is worse in the sitting position
Pain during bowel movements
Painful bumps near the anus
Diagnosis is made simply by looking at the area. Hemorrhoids will appear as bluish lumps at the edge of the anal opening. If the hemorrhoid is internal, the diagnosis is made through a rectal exam with a gloved finger.
Hemorrhoids only require treatment when symptomatic. Treatments for hemorrhoids include the following:
• Mild corticosteroid creams, such as Anusol HCTM, or wipes, such as TucksTM pads, to help reduce pain and swelling.
• Stool softeners to decrease further trauma to the inflamed tissue.
• Witch hazel compresses to reduce itching.
• Warm water baths (sitz baths) to reduce general discomfort.
Even painful hemorrhoids will usually go away by themselves over a few weeks, but sometimes the discomfort is so severe that you may be required to remove the clot from the swollen vein. This is performed by incising the skin over the hemorrhoid and draining the clotted blood.
A scalpel may be used (preferably under local anesthesia) to incise the hemorrhoid after cleaning the area thoroughly with Betadine. Cut just deep enough to evacuate the clot. The patient should experience quick relief as a result. Gauze pads should be placed at the site to absorb any bleeding. In rare cases, a suture may be needed.
It should be noted that this procedure is not the best way to remove a hemorrhoid, as simple incision does not remove it in its entirety. It may come back at a later time. Modern procedures, such as placing bands around the hemorrhoid, are less traumatic and more permanent in their results.
BIRTH CONTROL, PREGNANCY, AND DELIVERY
It’s a rare individual who doesn’t have a wife, girlfriend, mother, daughter or granddaughter that isn’t of childbearing age (13–50 years old). In a long-term disaster, society will be unstable and organized medical care will be spotty at best, nonexistent at worst. One of the least welcome events might be one that, for many families, is ordinarily considered a blessing: a pregnancy.
A pregnancy and the possible complications that accompany it will be a burden in a disaster. A pregnant woman will be at less than 100 percent efficiency at the exact wrong time, and complications could occur.
The death rate among pregnant women (also known as the maternal mortality rate) at the time of the American Revolution was about 2–4 percent per pregnancy. Given that the average woman in the year 1800 could expect 6–10 pregnancies over the course of her reproductive life, the cumulative maternal mortality rate easily approached 25 percent. That means that one out of four women died from complications of being pregnant, either early, during the childbirth, or even soon after a successful delivery.
If a major disaster occurs, women might face unacceptable levels of risk. There won’t be either medicine or medical supplies in which to treat pregnancy and childbirth complications. Deaths may happen simply because there are no IV fluids or medications to stop bleeding or treat infection.
When a pregnancy goes wrong, it takes away a valuable contributor from the family (sometimes permanently) and places an additional strain on resources and manpower.
Pregnancy Complications
The reasons that women could cease to become productive group members (or even die) during pregnancy or childbirth include the following:
Hyperemesis gravidarum. Simply put, this is excessive vomiting in early pregnancy. Everyone’s nauseous when they’re pregnant, but a few will have such extreme vomiting as to become severely dehydrated. Without IV fluid replacement, some of these patients might not survive.
Miscarriage. Approximately 10 percent of all pregnancies end in miscarriage. When a woman miscarries, she might not pass all of the dead tissue relating to the pregnancy. This tissue may become infected or cause excessive bleeding.
The treatment in this case would be dilatation and curettage (D&C), a procedure in which scrapers called curettes are used to remove the retained tissue. Without the right equipment and experience, some women might succumb.
Pregnancy-induced hypertension. Blood pressure may rise to dangerous levels and cause alarming amounts of swelling, sometimes throughout the body. This mostly is seen in the last 3 months of a first pregnancy. Left untreated, this condition leads to seizures and can be life threatening. Without modern facilities, bed rest (lying on the left side is best) may be just about all that you can do.
Childbirth issues. The delivery itself, although usually straightforward, can be fraught with complications. Excessive bleeding could occur before, during or after delivery due to vaginal tears or premature separation of the placenta from the uterus. The placenta ordinarily is expelled spontaneously within minutes after the delivery; however, there are occasions where it is “stuck” and must be manually removed. In these cases, portions of the placenta may remain lodged in the uterine walls, leading to bleeding and/or infection. Failure of the uterine walls to contract after delivery may also cause hemorrhage.
Pregnancy Care Basics
You may find yourself responsible for the care of a pregnant woman. It will be important to know how to support that pregnancy and, eventually, deliver that baby.
Without access to prenatal megavitamins, babies will be smaller at birth. This may also not be so bad, since having a Caesarean section won’t be available. It’s less traumatic for the mother to deliver a 6–7 pound baby than a 10 pounder.
Despite all the possible complications mentioned in the previous section, pregnancy is still a natural process. It usually proceeds without major complications and ends in the delivery of a normal baby. Although your pregnant patient will not be as productive for the survival group as she would ordinarily be, she will probably still be able to contribute to help make your efforts a success. The medic will need to know pregnancy care and how to deliver the fetus.
Today, we have simple tests that can identify pregnancy almost before a woman misses her period, but what if these tests are no longer available? You will have to rely on the following tried and true signs and symptoms to identify the condition:
Absent menstruation
Tender breasts
Nausea and vomiting
Darkening of the nipples, areola, or both
Fatigue
Frequent urination
Backache
These symptoms, in combination, indicate pregnancy. The timing of each will be variable: some will be noticed earlier than others. It should be noted that this investigation will be necessary only in those women experiencing their first pregnancy. Once a woman has been pregnant, she will usually just know when it happens again.
For more about the monitoring and care of a pregnancy, consider getting a copy of our book The Survival Medicine Handbook.
Normal Delivery
As the woman approaches her due date, several things will happen. The fetus will begin to drop lower in the pelvis. The patient’s abdomen may look different, or the top of the uterus (fundus) may appear lower. As the neck of the uterus (cervix) relaxes, the patient may notice a mucus-like discharge, sometimes with a bloody component. This is referred to as the “bloody show” and is usually a sign that things will be happening soon.
If you examine your patient vaginally by gently inserting two fingers of a gloved hand, you’ll notice the cervix is firm, like your nose, when the due date is approaching and soft, like your lips, when it isn’t. This softening of the cervix is called “effacement.” As labor progresses, the cervical walls will thin out until they are as thin as paper.
Dilation of the cervical opening will be slow at first, and speed up once it reaches about 3–4 cm. At this level of dilation, you will be able to place two (normal-sized) fingertips in the cervix and feel something firm; this is the baby’s head. Frequent vaginal exams are invasive, however, and not necessary in most cases.
Contractions will start becoming more frequent. To identify a contraction, feel the skin on the soft area of your cheek, and then touch your forehead. A contraction will feel firm like your forehead. False labor contractions will be irregular and will go away with bed rest (especially when the patient lies on her left side) and hydration. If contractions are coming faster and more furious, even with bed rest and hydration, it is probably the real thing! A gush of watery fluid from the vagina will often signify the “water breaking” (rupture of the amniotic sac) and is also a sign of impending labor and delivery. The timing, however, will be highly variable.
To prepare for delivery, wash your hands and put gloves on. Then, set up clean sheets so that there will be the least contamination possible. Tuck a sheet under the mother’s buttocks and spread it on your lap so that the baby, which comes out very slippery, will land onto the sheet instead of landing on the floor if you lose your grip. Place a towel on the mother’s belly; this is where the baby will go once it is delivered. Delivery kits are available online with everything you need, including drapes, clamps, and bulb syringes. To prevent infection, avoid touching anything but mother and baby if you can.
As the labor progresses, the baby’s head will move down the birth canal and the vagina will begin to bulge. When the baby’s head begins to become visible, it is called “crowning.” If the water has not yet broken (which can happen even at this late stage), the lining of the bag of water will appear as a slick gray surface. Some pressure on the membrane will rupture it, which is okay at this point. It might help the process along.
To make space, place two gloved fingers along the edge of the vagina by the perineum, the area between the vagina and anus. Using gentle pressure, move your fingers from side to side. This will stretch the area somewhat to give the baby a little more room to come out.
With each contraction, the baby’s head will come out a little more. Don’t be concerned if it goes back after the contraction. It should make steady progress, with more and more of the head becoming visible. Encourage the mother to help by taking a deep breath with each contraction and then pushing while slowly exhaling.
As the baby’s head emerges, it will usually face straight down or up, and then turn to the side. The cord might appear to be wrapped around its neck. If this is the case, gently slip the cord over the baby’s head. In cases where the cord is very tight and is preventing delivery, you may choose to doubly clamp it and cut between. This will release the tension and make delivery easier.
Next, gently hold each side of the baby’s head and apply gentle traction straight down. This will help the top shoulder out of the birth canal. Then, raise the head to release the bottom shoulder. Once the shoulders are out, the baby will deliver with one last push. The mother can now rest.
Put the baby immediately on the mother’s belly and clean out its nose and mouth with a bulb syringe. It will usually begin crying, which is a good sign that it is a vigorous infant. If it doesn’t, stimulate it by rubbing the baby’s back. (Spanking its bottom is more a cliché than recommended procedure.)
Dry the baby and wrap it up in a small towel or blanket. At this point, you may clamp the cord twice (2 inches apart) with Kelly or umbilical clamps, and cut in between with a scissors. There is no hurry to perform this procedure.
Once the baby has delivered, it’s the placenta’s turn. Be patient: In most cases, the placenta will deliver by itself in a few minutes. Pulling on the umbilical cord to force the placenta out is usually a bad idea. Breaking the cord because the placenta will not come out will require your placing your hand deep in the uterus to extract it. This is traumatic and can introduce infection. You can ask the mother to give a push when it’s clear the placenta is almost out.
If traction is necessary for some reason to get the placenta to deliver, place your fingers above the pubic bone and press as you apply mild traction. This will prevent the uterus’ being turned inside out (a potentially life-threatening situation) if the placenta is stubborn. A moderate amount of bleeding is not unusual after delivery of the afterbirth.
Once the placenta is out, examine it. The fetal surface (the surface to which the fetus was attached) is grey and shiny; turn it inside out and you will see the maternal surface, which looks like a rough version of liver. If a portion of the placenta remains inside, you may have to extract it manually.
The uterus (the top of which is now around the level of the belly button) contracts to control bleeding naturally. In a long labor, the uterus may be as tired as the mother after delivery and may be slow to contract. This may cause excessive bleeding. Gentle massage of the top of the fundus will make it firm again and thus limit blood loss. You may have to do this from time to time during the first 24 hours or so after delivery.
Monitor the mother closely for excessive bleeding over the next few days. In normal situations, the bleeding will become more and more watery as time progresses. This is normal. Also keep an eye out for evidence of fever, foul discharge, or other issues.
Place the baby on the mother’s breast soon after delivery. This will begin the secretion of colostrum, a form of milk produced by the breast that appears as a thick, yellowish liquid; it is rich in substances that will increase the baby’s resistance to infection. Suckling also causes the uterus to contract, a factor in decreasing blood loss.
It should be noted that there are different schools of thought regarding some of the above information about delivery. Remember that your goal is to have an end result of a healthy mother and baby, both physically and emotionally.